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J Am Coll Cardiol, 2006; 48:1538-1547, doi:10.1016/j.jacc.2006.02.078 (Published online 25 September 2006).
© 2006 by the American College of Cardiology Foundation
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CARDIOVASCULAR GENOMIC MEDICINE

Circulating Endothelial Cells in Cardiovascular Disease

Christopher J. Boos, MRCP, Gregory Y.H. Lip, MD and Andrew D. Blann, PhD*

Haemostasis, Thrombosis, and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, United Kingdom

Manuscript received December 13, 2005; revised manuscript received February 8, 2006, accepted February 14, 2006.

* Reprint requests and correspondence: Dr. Andrew D. Blann, University Department of Medicine City Hospital, Haemostasis, Thrombosis, and Vascular Biology, Dudley Road, Birmingham B18 7QH, United Kingdom (Email: a.blann{at}bham.ac.uk).


   Abstract
Top
 Abstract
Origins of CECs
 Isolation of CECs
 The relationship between CECs,...
 CECs and disease
 CECs in CVD
 Is there a relationship...
 References
 
Quantification of circulating endothelial cells (CECs) in peripheral blood is developing as a novel and reproducible method of assessing endothelial damage/dysfunction. The CECs are thought to be mature cells that have detached from the intimal monolayer in response to endothelial injury and are a different cell population to endothelial progenitor cells (EPCs). The EPCs are nonleukocytes derived from the bone marrow that are believed to have proliferative potential and may be important in vascular regeneration. Currently accepted methods of CEC quantification include the use of immunomagnetic bead separation (with cell counting under fluorescence microscopy) and flow cytometry. Several recent studies have shown increased numbers of CECs in cardiovascular disease and its risk factors, such as unstable angina, acute myocardial infarction, stroke, diabetes mellitus, and critical limb ischemia, but no change in stable intermittent claudication, essential hypertension, or atrial fibrillation. Furthermore, CEC quantification at 48 h after acute myocardial infarction has been shown to be an accurate predictor of major adverse coronary events and death at both 1 month and 1 year. This article presents an overview of the pathophysiology of CECs in the setting of cardiovascular disease and a brief comparison with EPCs.

Abbreviations and Acronyms
  AF = atrial fibrillation
  CAD = coronary artery disease
  CEC = circulating endothelial cell
  CVD = cardiovascular disease
  EPC = endothelial progenitor cell
  FMD = flow-mediated dilatation
  MI = myocardial infarction
  PVD = peripheral vascular disease
  VEGFR = vascular endothelial growth factor receptor
  vWf = von Willebrand factor

Cardiovascular disease (CVD) is the leading cause of death and disability in the developed world, and is projected to soon overtake infectious disease as the preeminent cause of death worldwide. Accounting for 49% of all deaths in Europe and 30% of all deaths before the age of 65 years, it contributes substantially to the escalating cost of health care (1–3). The reasons for this generally reflect an increasing prevalence of several known CVD risk factors: obesity and insulin resistance, diabetes, smoking, hypertension, poor diet, and an increasing ageing population (2,4). The spectrum of CVD is wide and includes coronary artery disease (CAD), peripheral vascular disease (PVD), congestive heart failure, and atrial fibrillation (AF), stroke, in addition to the major risk factors of hypertension, hypercholesterolemia, smoking, and diabetes mellitus. A commonality between these conditions is the loss of appropriate endothelial physiology (damage/injury, leading to dysfunction) that is paramount to the maintenance of vascular hemostasis and blood pressure control (5).

However, it is now recognized that up to half of patients presenting with a clinical manifestation of CVD do not possess any of the traditional risk factors (4). Hence, there is growing interest in the identification of other risk factors or markers (such as for assessing vascular injury) that may facilitate improved measures for the primary and secondary prevention of CVD (5). Methods for assessing endothelial function include the quantification of changes in coronary and brachial artery blood flow (the latter generally referred to as flow-mediated dilatation [FMD]) and abnormal release of plasma markers such as von Willebrand factor (vWf) (6–8). More recently, the measurement of immunologically defined circulating endothelial cells (CECs) in the peripheral blood is gaining ground as an important and novel technique for assessment of endothelial injury. The CECs are part of a family of blood-borne endothelioid cells that include endothelial progenitor cells (EPCs).

In this article we present a comprehensive overview of the pathophysiology of CECs and the value of CEC quantification as an important marker for CVD, and briefly compare them with EPCs. To do this we performed an on-line search of the publication databases Cochrane Reviews, PubMed, Medline, and Embase, using the key words circulating endothelial cells and endothelial progenitor cells.


   Origins of CECs
Top
 Abstract
 Origins of CECs
Isolation of CECs
 The relationship between CECs,...
 CECs and disease
 CECs in CVD
 Is there a relationship...
 References
 
Endothelial cells line the vascular tree and adhere to a basement membrane. In health, these cells would be expected to remain in this location, with perhaps a very low level of cell loss into the blood, with consequent clearance by the reticuloendothelial system. It would seem logical that pathological processes that cause damage to the endothelium might also cause endothelial cell detachment, resulting in increased numbers of CECs within the bloodstream (9). The mechanism of CEC detachment is complex and involves many factors, such as mechanical injury, the classic risk factors for atherosclerosis, alteration of endothelial/subendothelium cellular adhesion molecules, defective binding to anchoring matrix proteins, and cellular apoptosis with decreased survival of cytoskeletal proteins (9–11).

Current consensus supports the view that CECs represent a different population of cells from EPCs. The latter seem to be a heterologous population of largely bone marrow–derived large nonleukocyte cells with properties similar to those of embryonal angioblasts, at different stages of maturation, from early (vascular endothelial growth factor receptor [VEGFR]/CD133+) to a more mature (VEGFR/CD34+) phenotype. The EPCs have many properties that distinguish them from CECs (i.e., viability, forming colonies in vitro [12,13], and having the capacity to differentiate into mature endothelial cells [14–16]). Hence, EPCs represent a subset of cells at varying stages of development present in the peripheral bloodstream. In contrast, it is uncertain whether CECs are all truly viable because they are less likely to form colonies (if at all), some appearing in the circulation as irregular carcasses, as clumps of cells, or as filamentous cell remnants (9).

Broadly speaking, EPCs and CECs can be separated by identification of their surface markers: EPCs bear immaturity surface markers, such as CD34 and CD133, whereas CECs are positive for CD146 and negative for CD34 and CD133 (15–18). The CD146 molecule has clearly evolved as the most popular marker for the identification of CECs. This adhesion molecule is concentrated at the endothelial junction, where it plays a key role in the control of cell–cell cohesion, permeability, and signalization (19,20).


   Isolation of CECs
Top
 Abstract
 Origins of CECs
 Isolation of CECs
The relationship between CECs,...
 CECs and disease
 CECs in CVD
 Is there a relationship...
 References
 
Although the precise quantification of CECs is difficult (partly because of the low numbers present in the circulation and because of their differing morphologic appearances), their detection has been improved by cell enrichment techniques and cell labeling using relatively endothelial-specific markers. The CECs are counted in whole blood using either immunomagnetic separation or flow cytometry. The former method [full details of which are available elsewhere (9,17,21)] involves the use of 4.5-µm ferrous beads bound to an anti-CD146 monoclonal antibody. Briefly, these coated beads are mixed with venous blood in a head-over-head mixer for 30 min at 4°C. The anti-CD146–coated beads and blood/buffer mixture are placed in front of a magnet. The anti-CD146–coated beads (typically 5 x 107/ml of blood) bind to the CD146 epitope on the CECs and the magnet is then used to separate the bead-coated CECs from the other blood constituents. The unbound cells are washed away with buffer, and bound cells are retained on the magnet. After additional wash cycles, the cells are resuspended in buffer and labeled (e.g., with acridine orange) before manual counting in a glass counting chamber under a fluorescent microscope. The use of an Fc-blocking agent (to prevent nonspecific leukocyte binding) and relatively endothelial-specific Ulex europaeus lectin 1 has improved the specificity of this technique (Fig. 1). A CEC is defined as an event of appropriate size that binds (forms a rosette with) 4 or more beads (21). The endothelial (and nonleukocyte) origin of CD146-defined CECs has been amply shown by co-marking with, for example, vWf, endothelial nitric oxide synthase, and E-selectin; however, a notable caveat (especially in cancer) is that CD146 may also be found on trophoblasts, mesenchymal stem cells, periodontal tissue, and malignant (prostatic, melanoma) tissues (9).


Figure 1
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  		Figure 1 A circulating endothelial cell (stained bright green with Ulex europaeus lectin) forming a rosette with at least 10 immunomagnetic beads. Photomicrograph in epifluorescence (Zeiss), wet preparation, magnification x40. For scale, the large number of residual immunomagnetic beads each have a diameter of 4.5 µm.

 

   The relationship between CECs, CVD, and endothelial dysfunction
Top
 Abstract
 Origins of CECs
 Isolation of CECs
 The relationship between CECs,...
CECs and disease
 CECs in CVD
 Is there a relationship...
 References
 
Current well-accepted methods used to quantify the severity of endothelial damage/injury include vascular marker quantification (e.g., vWf, soluble E-selectin, soluble thrombomodulin), reduced FMD, and impaired skin blood flow response using laser Doppler flowmetry. There is a clearly shown association between almost all types of CVD (CAD [22,23], PVD [24], hypertension [25,26], stroke [27], heart failure [28,29], AF [30–32], and diabetes [33,34]) and the endothelial dysfunction that occurs after damage/injury. As indicated, the endothelial origin of CECs has been confirmed by the positive labeling for vWf, endothelial nitric oxide synthase, and E-selectin, but also for receptors for VEGF, the receptor of acetylated low-density lipoprotein cholesterol, thrombomodulin, and Ulex europaeus lectin 1 and by the identification of Weibel-Palade bodies (17,18,21,35).

There is increasing evidence to support the relationship between CECs and endothelial dysfunction. For example, an inverse correlation between CECs and FMD (a surrogate physiological marker of a disturbed endothelium) has been shown (36,37). In addition, a strong correlation between CECs and several plasma markers of endothelial injury (vWf, tissue plasminogen activator, soluble E-selectin) have also been shown (36–40). Figure 2 shows such a correlation between CECs and vWf in heart failure (39).


Figure 2
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  		Figure 2 Relationship of von Willebrand factor (vWf) and circulating endothelial cells (CECs) in heart failure. Spearman correlation, r = 0.463; p < 0.0001. Reprinted, with permission, from Chong et al. (37).

 

   CECs and disease
Top
 Abstract
 Origins of CECs
 Isolation of CECs
 The relationship between CECs,...
 CECs and disease
CECs in CVD
 Is there a relationship...
 References
 
The CECs are rarely found in normal healthy individuals, in the order of <3 cells/ml. Elevated numbers of CECs have been identified in a wide array of disease processes such as chronic venous insufficiency (41), aortitis (42), pulmonary hypertension (43), Behçet’s disease (44), septic shock (45), breast cancer (46), acute sickle cell crises (47), and thrombotic thrombocytopenia (48). Elevated CECs have also been shown to correlate with disease severity in a variety of diseases, including Mediterranean spotted fever (49), inflammatory vasculitis (18,50), Kawasaki disease (51), systemic lupus erythematosus (52), and in systemic sclerosis (53).

The CECs have been identified as a useful marker of endothelial damage and potential vascular rejection in kidney transplantation patients (54,55). Popa et al. (54) were able to show that the presence of donor CECs in recipient blood related to post-transplantation injury. More recently, Woywodt et al. (56) showed that in allogenic hematopoietic stem cell transplantation, those patients who received reduced-intensity conditioning had significantly lower CEC numbers.

The endothelium plays an important role in the spread and propagation of cancer cells. It is actively involved in angiogenesis (new vessel formation) and in metastasis (57). Increased CECs have been identified in both breast cancer and lymphoma, and their numbers have been shown to significantly correlate with plasma vascular cell adhesion molecule-1 and VEGF levels, although these molecules are not endothelial-specific (46,58,59).

In various diseases, the longitudinal quantification of CECs has shown that their levels vary according to the clinical condition/severity. Levels among patients who are acutely ill are higher than in those patients who are in clinical remission or in a recovery phase of the disease. From a pharmacologic point of view, several studies have also shown that CECs may be useful in monitoring therapeutic efficacy. For example, Woywodt et al. (50) showed a decrease in CECs during 6 months of successful treatment of anti-neutrophil cytoplasmic antibody–associated small-vessel vasculitis, whereas George et al. (60) showed a decrease in CECs with treatment of Rickettsial conorri infection in familial Mediterranean fever. In another study involving the treatment of disseminated human cytomegalovirus infection, there was a dramatic decrease in the CEC count from blood within just a few days of treatment by ganciclovir and foscarnet (61). In addition, CEC numbers are reported to be higher in those patients with progressive disease compared with those who have stable disease and with healthy controls (62).

The precise anatomic origin of CECs, i.e., arterial or venous, is unclear. However, several groups have used CD36 to show that in some circumstances, CECs may arise from the microvascular (47) or the macrovascular portion of the vascular tree (63).


   CECs in CVD
Top
 Abstract
 Origins of CECs
 Isolation of CECs
 The relationship between CECs,...
 CECs and disease
 CECs in CVD
Is there a relationship...
 References
 
CAD.   There have been several studies quantifying CECs in myocardial infarction (MI) (17,39,63–66) (Table 1). Despite small numbers, results are consistent: acute MI and unstable angina are both associated with significantly increased CEC counts compared with healthy controls, and CEC counts are either normal or only minimally elevated in patients with stable angina. The CEC counts in patients with acute coronary syndromes correlate with endothelial dysfunction (by measurement of vWf levels) and with the prothrombotic state (measurement of tissue factor levels) (39). In the study by Wang et al. (66), the investigators showed that CEC counts correlated with levels of inflammatory marker C-reactive protein, even after adjustment for confounding factors.


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  		Table 1. Studies Summarizing the Quantification of CECs in Coronary Artery Disease
 
Quilici et al. (64) showed that the combined use of CEC quantification with cardiac troponin measurement markedly improved diagnostic accuracy in patients presenting with non–ST-segment elevation MI. In addition, they were able to give some insight into the temporal pattern of CEC decrease. They showed that the highest CEC counts were obtained at the time of infarct presentation, with decreasing levels over the ensuing 8 h, with a steady decrease thereafter. However, this is in contrast to the much smaller study (only 5 patients were studied for temporal data) by Mutin et al. (63), in which maximal CEC levels in serial samples were found at 18 to 24 h after MI.

George et al. (17) plotted the effects of coronary angioplasty on CEC counts in 10 patients listed for elective coronary angioplasty. All patients had normal CEC counts before the procedure, with a peak increase in CEC counts to 8 to 15 cells/ml at 4 h after the procedure. The CEC counts in peripheral venous and arterial blood taken at 4 h were similar. There was then a gradual decrease in CEC counts over the ensuing 20 h toward near-baseline CEC levels.

PVD.   Peripheral vascular disease is a well-established predictor of cardiovascular risk in which disease severity relates to the level of vascular damage, prothrombotic markers, and endothelial dysfunction, all of which play a major role in atherosclerosis. There has been only 1 study to date designed to examine CEC counts in PVD severity (Table 2). Makin et al. (39) studied 4 patient groups, each of 20 patients, with lower limb ischemic rest pain, intermittent claudication, and acute MI, and healthy controls (the MI data has been presented above). They showed that CEC counts were elevated in patients with ischemic rest pain compared with normal levels among the patients with intermittent claudication and in healthy controls. Furthermore, levels of CECs correlated with plasma tissue factor (associated with a prothrombotic state) and vWf. Thus, increased CECs are present only in severe disease of the coronary (acute MI, unstable angina) and peripheral circulation (ischemic rest pain), not in relatively stable disease of those vessels (i.e., stable angina and intermittent claudication).


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  		Table 2. CEC Quantification in Other Cardiovascular Disease States
 
Stroke, hypertension, and AF.   Because stroke is well known to be associated with endothelial abnormalities, it would be reasonable to speculate that CECs would also be increased in patients with this condition, and that they would correlate with other indices of endothelial dysfunction. There have been 2 studies investigating CEC quantification in stroke. Freestone et al. (67) looked at patients with AF and stroke as part of a broader study of CECs in AF. They found higher levels of CECs in patients with concurrent AF and a history of stroke compared with healthy controls in sinus rhythm, and that CECs correlated with vWf. Nadar et al. (68) studied 29 patients presenting with stroke and hypertension (but no AF), and compared them with 30 high-risk hypertensive patients (Table 2) and 30 normotensive controls. Compared with the other 2 groups, the patients with acute ischemic stroke had significantly higher numbers of CECs per milliliter in venous blood and higher levels of vWf and soluble E-selectin. In addition, the numbers of CECs correlated with both vWf and soluble E-selectin.

It is somewhat surprising that CEC counts were normal in high-risk hypertensive controls because these patients are known to have marked endothelial dysfunction (25,26,69). However, it would seem that perhaps, as in the case of chronic stable angina, a certain threshold level of endothelial injury is required to cause CEC detachment from the endothelium. Notably, Bull et al. (43) reported increased CECs in primary and secondary pulmonary hypertension.

Heart failure.   Chong et al. (37) tested the hypothesis of a clear relationship between the endothelial dysfunction (defined by FMD, vWf, and soluble thrombomodulin) and CECs in patients with chronic HF. Among the patients with HF there was a 3-fold higher level of CECs, but no difference in soluble thrombomodulin, compared with controls. In addition, there was also a positive correlation between CECs and vWF, confirming the ability of CECs to predict endothelial dysfunction. They subsequently reported equally raised CECs in acute HF as in chronic HF (70).

Diabetes.   McClung et al. (71) investigated the presence of CECs in the peripheral blood of 25 patients with diabetes mellitus and in 9 nondiabetic control donors (Table 2). They showed that patients with diabetes mellitus had an elevated number of CECs compared with healthy controls. However, CEC counts did not correlate with the levels of hemoglobin A1c and were independent of plasma glucose levels.

CECs and the prediction of cardiovascular events.   Koc et al. (72) asked whether or not CEC counts would be predictive of cardiovascular events in hemodialysis subjects at increased risk for CVD. They studied 2 patient cohorts: in the first, CEC numbers were determined in 29 hemodialysis patients followed up for a mean of 470 days; in the second cohort of 44 hemodialysis patients, they analyzed the association between CEC counts with other markers of vascular inflammation. Seven of the 19 subjects with elevated CECs (defined as >19 cells/ml) had cardiovascular events during follow-up, compared with no events among the low CEC count population (p = 0.04). Among the second cohort, there was a positive correlation between CEC counts and high-sensitivity C-reactive protein, interleukin-6, interleukin-10, monocyte chemoattractant protein-1, and soluble vascular cell adhesion molecule-1.

Lee et al. (65) asked the same question in patients admitted to a coronary care unit with the diagnosis of an acute coronary syndrome. Compared with interleukin-6 (a proinflammatory cytokine) and plasma vWf, high numbers of CECs 48 h after admission were the only predictor of both major adverse coronary events and death at 1 month and 1 year.

Although strictly speaking not CVD, when defining CECs by intracellular vWf and the expression of the VEGF receptor KDR, Mutunga et al. (73) reported high numbers of CECs in those patients who died of septic shock compared with those who had similar disease but survived.


   Is there a relationship between CECs and EPCs?
Top
 Abstract
 Origins of CECs
 Isolation of CECs
 The relationship between CECs,...
 CECs and disease
 CECs in CVD
 Is there a relationship...
References
 
A current theory is that increased numbers of CECs reflect severe endothelial damage, and that therefore there are areas of the subendothelium that are denuded and that potentially may attract platelets (9). In parallel is the hypothesis that EPCs are restorative/regenerative cells, possibly destined to replace/renew damaged areas of the intima (15,74–77). Are these theories related?

Are numbers of CECs and EPCs inversely related?.   The current literature has largely shown elevated numbers of CECs, yet reduced numbers of EPCs, among a broad spectrum of patients with CVD and its risk factors, raising the suggestion of an inverse relationship (37,39,63,71,76–81). It may be that the disease process that drives mural endothelial cells into the blood to become CECs also influences (reduces) levels of EPCs. However, the reality is likely to be far more complex than merely a reciprocal situation. For example, in acute MI elevated numbers of both CECs and EPCs have been shown (17,39,63–66,82–84). Furthermore, stimulatory/therapeutic factors (e.g., statins and endurance training) among patients with CAD leads to both improved endothelial function and increased EPC counts, although the relationship between therapeutic factors and decreasing CEC counts has not been studied for CVD (85–87). In addition, there have been no studies to date that have actually attempted to quantify both CECs and EPCs simultaneously in the same patient population.

Are CECs and EPCs phylogenetically related?.   However, much of the above presupposes that CECs and EPCs are entirely different cells. This view may be premature, and the 2 cells types may share a common cell biology. Although ultimately defined by different laboratory techniques (immunomagnetic beads or flow cytometry for CECs alongside flow cytometry and/or tissue culture for EPCs), the initial problem is with the distribution of the particular molecules purported to define each cell type (i.e., CD146 for CECs and any combination of CD34, CD133, VEGFR-2, and so on, for EPCs) (12–17). It seems likely that under certain conditions, a small number of cells bear both CD146 and CD34 (53,88–90), possibly leading to difficulties in interpretation, especially as both CECs and EPCs are present in very small numbers. Notably, for example, Nakatani et al. (91) estimated that 0% to 18% of CD146-defined CECs from patients with Kawasaki disease were also positive for CD133. Although much development work has been performed in vitro (92) (e.g., changes in proportions of cells bearing CD34 and CD133) (90), a parallel with the clinical situation cannot necessarily be assumed.

Some of these issues may be partially resolved with additional phenotyping. The endothelioid nature of CECs and EPCs is generally presumed by staining for vWf, lectins (e.g., Ulex europaeus), endothelial nitric oxide synthase, and acetylated low-density lipoprotein cholesterol (9,90). However, the anatomical origin of CECs can be traced with the use of CD36, a microvascular marker (40,43,47,58,63,65), and others have used E-selectin and intracellular adhesion molecule-1 expression to quantify activation (40,43,53,63). Although it is known that atherosclerosis is an arterial disease, it is not known whether or not CECs arise from the arterial or the venous circulation, although the use of CD45 to exclude a leukocyte origin for these cells is common (53,58,65).

The heterogenous nature of EPCs.   As mentioned, a problem is the definition of an EPC, because many markers are available (CD34, CD133, VEGFR-2) (12–16,90). A further growing issue with EPCs is the question of a monocytic origin for these cells. Current data tend to suggest that under angiogenic stimulation, monocytes (bearing CD14) have the capacity to develop an endothelial phenotype with expression of specific surface markers and even form cord- and tubular-like structures in vitro (93,94). The relationship between monocytes and EPCs is complex; there are clearly EPCs that are nonmonocytic, but there also seem to be monocytes that possess both functional characteristics and, perhaps, surface markers (in lower numbers) for CECs and EPCs, and vice versa (95–97). However, despite differences in their derivation, EPCs possess the commonality of being capable of augmenting revascularization and endothelial regeneration. This problem of heterogeneity is compounded by the different names (endothelial outgrowth cells [98], circulating angiogenic cells [99], endothelial-like cells [100]) given to possibly overlapping cell types.

Conclusions.   The measurement of immunologically defined CECs and EPCs in venous blood now represents an important and novel technique for assessment of endothelial injury and repair (Fig. 3). Circulating endothelial cells are biomarkers of damage, and high levels predict a poor outcome (9,65). Endothelial progenitor cells are biomarkers of repair with therapeutic potential, and low levels predict a poor outcome (76,101). It may be that damage to mural endothelial cells that lead to increased CECs is physiologically restored by EPCs. Levels of CECs in the bloodstream have been shown to significantly correlate with several well-established plasma and physiological markers of endothelial function, are technically simple to measure (102), are elevated in a wide spectrum of conditions, and are predictive of major adverse cardiovascular end points and death in patients with acute coronary syndromes. As such, they represent one of the first specific cellular markers to provide a direct link with the pathophysiology of CVD. Bonello et al. (103) have shown increased CECs and mobilization of EPCs after coronary angioplasy.


Figure 3
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  		Figure 3 Simplified discrimination of endothelial progenitor cells from circulation endothelial cells. CEC = circulating endothelial cell, EC = mural endothelial cell, EPC = endothelial progenitor cell.

 


   Footnotes
 
Cardiovascular Genomic Medicine series edited by Geoffrey S. Ginsburg, MD, PhD.


   References
Top
 Abstract
 Origins of CECs
 Isolation of CECs
 The relationship between CECs,...
 CECs and disease
 CECs in CVD
 Is there a relationship...
 References
 

  1. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study Lancet 1997;349:1436-1442.[CrossRef][ISI][Medline]
  2. De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European Society of CardiologyAmerican Heart AssociationAmerican College of Cardiology European guidelines on cardiovascular disease prevention in clinical practice Atherosclerosis 2004;173:381-391.[CrossRef][Medline]
  3. Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J. The health care burden of acute chest pain Heart 2005;91:229-230.[Free Full Text]
  4. EUROASPIRE II Study Group Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme Eur Heart J 2001;22:554-572.[Abstract/Free Full Text]
  5. Blann AD. Assessment of endothelial dysfunction: focus on atherothrombotic disease Pathophysiol Haemost Thromb 2004;33:256-261.
  6. Zeiher AM, Drexler H, Saurbier B, Just H. Endothelium-mediated coronary blood flow modulation in humansEffects of age, atherosclerosis, hypercholesterolemia, and hypertension. J Clin Invest 1993;92:652-662.[ISI][Medline]
  7. Anderson TJ, Uehata A, Gerhard, MD, et al. Close relation of endothelial function in the human coronary and peripheral circulations J Am Coll Cardiol 1995;26:1235-1241.[Abstract]
  8. Boneu B, Abbal M, Plante J, Bierme R. Factor VIII-complex and endothelial damage Lancet 1975;i:1430.
  9. Blann AD, Woywodt A, Bertolini F, et al. Circulating endothelial cellsBiomarker of vascular disease. Thromb Haemost 2005;93:228-235.[ISI][Medline]
  10. Ruegg C, Yilmaz A, Bieler G, Bamat J, Chaubert P, Lejeune FJ. Evidence for the involvement of endothelial cell integrin alphaVbeta3 in the disruption of the tumour vasculature induced by TNF and IFN-gamma Nat Med 1998;4:408-414.[CrossRef][ISI][Medline]
  11. Re F, Zanetti A, Sironi M, et al. Inhibition of anchorage-dependent cell spreading triggers apoptosis in cultured human endothelial cells J Cell Biol 1994;127:537-546.[Abstract/Free Full Text]
  12. Rafii S, Shapiro F, Rimarachin J, et al. Isolation and characterization of human bone marrow microvascular endothelial cells: hematopoietic progenitor cell adhesion Blood 1994;84:10-19.[Abstract/Free Full Text]
  13. Boyer M, Townsend LE, Vogel LM, et al. Isolation of endothelial cells and their progenitor cells from human peripheral blood J Vasc Surg 2000;31:181-189.[CrossRef][ISI][Medline]
  14. Asahara T, Murohara T, Sullivan A, et al. Isolation of putative progenitor endothelial cells for angiogenesis Science 1997;275:964-967.[Abstract/Free Full Text]
  15. Hristov M, Erl W, Weber PC. Endothelial progenitor cells: mobilization, differentiation, and homing Arterioscler Thromb Vasc Biol 2003;23:1185-1189.[Abstract/Free Full Text]
  16. Bompais H, Chagraoui J, Canron X, et al. Human endothelial cells derived from circulating progenitors display specific functional properties compared with mature vessel wall endothelial cells Blood 2004;103:2577-2584.[Abstract/Free Full Text]
  17. George F, Brisson C, Poncelet P, et al. Rapid isolation of human endothelial cells from whole blood using S-Endo1 monoclonal antibody coupled to immuno-magnetic beads: demonstration of endothelial injury after angioplasty Thromb Haemost 1992;67:147-153.[ISI][Medline]
  18. George F, Poncelet P, Laurent JC, et al. Cytofluorometric detection of human endothelial cells in whole blood using S-Endo 1 monoclonal antibody J Immunol Methods 1991;139:65-75.[CrossRef][ISI][Medline]
  19. Bardin N, Anfosso F, Masse JM, et al. Identification of CD146 as a component of the endothelial junction involved in the control of cell-cell cohesion Blood 2001;98:3677-3684.[Abstract/Free Full Text]
  20. Anfosso F, Bardin N, Vivier E, Sabatier F, Sampol J, Dignat-George F. Outside-in signaling pathway linked to CD146 engagement in human endothelial cells J Biol Chem 2001;276:1564-1569.[Abstract/Free Full Text]
  21. Woywodt A, Goldberg C, Scheer J, Regelsberger H, Haller H, Haubitz M. An improved assay for enumeration of circulating endothelial cells Ann Hematol 2004;83:491-494.[ISI][Medline]
  22. Forgione MA, Leopold JA, Loscalzo J. Roles of endothelial dysfunction in coronary artery disease Curr Opin Cardiol 2000;15:409-415.[CrossRef][ISI][Medline]
  23. Jambrik Z, Venneri L, Varga A, Rigo F, Borges A, Picano E. Peripheral vascular endothelial function testing for the diagnosis of coronary artery disease Am Heart J 2004;148:684-689.[CrossRef][ISI][Medline]
  24. Brevetti G, Silvestro A, Schiano V, Chiariello M. Endothelial dysfunction and cardiovascular risk prediction in peripheral arterial disease: additive value of flow-mediated dilation to ankle-brachial pressure index Circulation 2003;108:2093-2098.[Abstract/Free Full Text]
  25. Perticone F, Ceravolo R, Pujia A, et al. Prognostic significance of endothelial dysfunction in hypertensive patients Circulation 2001;104:191-196.[Abstract/Free Full Text]
  26. Schmieder RE, Weihprecht H, Schobel H, et al. Is endothelial function of the radial artery altered in human essential hypertension? Am J Hypertens 1997;10:323-331.[CrossRef][ISI][Medline]
  27. Zvan B, Zaletel M, Pogacnik T, Kiauta T. Testing of cerebral endothelium function with L-arginine after stroke Int Angiol 2002;21:256-259.[ISI][Medline]
  28. Landmesser U, Spiekermann S, Dikalov S, et al. Vascular oxidative stress and endothelial dysfunction in patients with chronic heart failure: role of xanthine-oxidase and extracellular superoxide dismutase Circulation 2002;106:3073-3078.[Abstract/Free Full Text]
  29. de Jong RM, Blanksma PK, Cornel JH, et al. Endothelial dysfunction and reduced myocardial perfusion reserve in heart failure secondary to coronary artery disease Am J Cardiol 2003;91:497-500.[CrossRef][ISI][Medline]
  30. Marin F, Roldan V, Climent VE, et al. Plasma von Willebrand factor, soluble thrombomodulin, and fibrin D-dimer concentrations in acute onset non-rheumatic atrial fibrillation Heart 2004;90:1162-1166.[Abstract/Free Full Text]
  31. Conway DS, Pearce LA, Chin BS, Hart RG, Lip GY. Prognostic value of plasma von Willebrand factor and soluble P-selectin as indices of endothelial damage and platelet activation in 994 patients with nonvalvular atrial fibrillation Circulation 2003;107:3141-3145.[Abstract/Free Full Text]
  32. Conway DS, Pearce LA, Chin BS, Hart RG, Lip GY. Plasma von Willebrand factor and soluble P-selectin as indices of endothelial damage and platelet activation in 1321 patients with nonvalvular atrial fibrillation: relationship to stroke risk factors Circulation 2002;106:1962-1967.[Abstract/Free Full Text]
  33. Dandona P, Chaudhuri A, Aljada A. Endothelial dysfunction and hypertension in diabetes mellitus Med Clin North Am 2004;88:911-931.[CrossRef][ISI][Medline]
  34. Kimura Y, Matsumoto M, Miyauchi E, Deng YB, Iwai K, Hattori H. Noninvasive detection of endothelial dysfunction in elderly with NIDDM by ultrasonography Echocardiography 2001;18:559-564.[CrossRef][ISI][Medline]
  35. Grefte A, van der Giessen M, van Son W, The TH. Circulating cytomegalovirus (CMV)-infected endothelial cells in patients with an active CMV infection J Infect Dis 1993;167:270-277.[ISI][Medline]
  36. Rajagopalan S, Somers EC, Brook RD, et al. Endothelial cell apoptosis in systemic lupus erythematosus: a common pathway for abnormal vascular function and thrombosis propensity Blood 2004;103:3677-3683.[Abstract/Free Full Text]
  37. Chong AY, Blann AD, Patel J, Freestone B, Hughes E, Lip GY. Endothelial dysfunction and damage in congestive heart failure: relation of flow-mediated dilation to circulating endothelial cells, plasma indexes of endothelial damage, and brain natriuretic peptide Circulation 2004;110:1794-1798.[Abstract/Free Full Text]
  38. Mancuso P, Calleri A, Cassi C, et al. Circulating endothelial cells as a novel marker of angiogenesis Adv Exp Med Biol 2003;522:83-97.[ISI][Medline]
  39. Makin A, Chung NAY, Silverman SH, Blann A, Lip GY. Assessment of endothelial damage in atherosclerotic vascular disease by quantification of circulating endothelial cells Eur Heart J 2004;25:371-376.[Abstract/Free Full Text]
  40. Butthep P, Rummavas S, Wisedpanichkij R, Jindadamrongwech S, Fucharoen S, Bunyaratvej A. Increased circulating activated endothelial cells, vascular endothelial growth factor, and tumor necrosis factor in thalassemia Am J Hematol 2002;70:100-106.[CrossRef][ISI][Medline]
  41. Janssens D, Michiels C, Guillaume G, Cuisinier B, Louagie Y, Remacle J. Increase in circulating endothelial cells in patients with primary chronic venous insufficiency: protective effect of Ginkor Fort in a randomized double-blind, placebo-controlled clinical trial J Cardiovasc Pharmacol 1999;33:7-11.[CrossRef][ISI][Medline]
  42. Dang A, Wang B, Li W, et al. Plasma endothelin-1 levels and circulating endothelial cells in patients with aortoarteritis Hypertens Res 2000;23:541-544.[ISI][Medline]
  43. Bull TM, Golpon H, Hebbel RP, et al. Circulating endothelial cells in pulmonary hypertension Thromb Haemost 2003;90:698-703.[ISI][Medline]
  44. Camoin-Jau L, Kone-Paut I, Chabrol B, Sampol J, Dignat-George F. Circulating endothelial cells in Behcet’s disease with cerebral thrombophlebitis Thromb Haemost 2000;83:631-632.[ISI][Medline]
  45. Mutunga M, Fulton B, Bullock R, et al. Circulating endothelial cells in patients with septic shock Am J Respir Crit Care Med 2001;163:195-200.[Abstract/Free Full Text]
  46. Furstenberger G, von Moos R, Senn HJ, Boneberg EM. Real-time PCR of CD146 mRNA in peripheral blood enables the relative quantification of circulating endothelial cells and is an indicator of angiogenesis Br J Cancer 2005;93:793-798.[CrossRef][ISI][Medline]
  47. Solovey A, Lin Y, Browne P, Choong S, Wayner E, Hebbel RP. Circulating activated endothelial cells in sickle cell anaemia N Engl J Med 1997;337:1584-1590.[Abstract/Free Full Text]
  48. Lefevre P, George F, Durand JM, Sampol J. Detection of circulating endothelial cells in thrombotic thrombocytopenic purpura Thromb Haemost 1993;69:522.[ISI][Medline]
  49. Drancourt M, George F, Brouqui P, Sampol J, Raoult D. Diagnosis of Mediterranean spotted fever by indirect immunofluorescence of Rickettsia conorii in circulating endothelial cells isolated with monoclonal antibody-coated immunomagnetic beads J Infect Dis 1992;166:660-663.[ISI][Medline]
  50. Woywodt A, Streiber F, de Groot K, Regelsberger H, Haller H, Haubitz M. Circulating endothelial cells as markers for ANCA-associated small-vessel vasculitis Lancet 2003;361:206-210.[CrossRef][ISI][Medline]
  51. Nakatani K, Takeshita S, Tsujimoto H, Kawamura Y, Tokutomi T, Sekine I. Circulating endothelial cells in Kawasaki disease Clin Exp Immunol 2003;131:536-540.[CrossRef][ISI][Medline]
  52. Clancy R, Marder G, Martin V, Belmont HM, Abramson SB, Buyon J. Circulating activated endothelial cells in systemic lupus erythematosus: further evidence for diffuse vasculopathy Arthritis Rheum 2001;44:1203-1208.[CrossRef][ISI][Medline]
  53. Del Papa N, Colombo G, Fracchiolla N, et al. Circulating endothelial cells as a marker of ongoing vascular disease in systemic sclerosis Arthritis Rheum 2004;50:1296-1304.[CrossRef][ISI][Medline]
  54. Popa ER, Kas-Deelen AM, Hepkema BG, Van Son WJ, The TH, Harmsen MC. Donor-derived circulating endothelial cells after kidney transplantation Transplantation 2002;74:1320-1327.[CrossRef][ISI][Medline]
  55. Woywodt A, Schroeder M, Gwinner W, et al. Elevated numbers of circulating endothelial cells in renal transplant recipients Transplantation 2003;76:1-4.[ISI][Medline]
  56. Woywodt A, Scheer J, Hambach L, et al. Circulating endothelial cells as a marker of endothelial damage in allogeneic hematopoietic stem cell transplantation Blood 2004;103:3603-3605.[Abstract/Free Full Text]
  57. Mancuso P, Calleri A, Cassi C, et al. Circulating endothelial cells as a novel marker of angiogenesis Adv Exp Med Biol 2003;522:83-97.[ISI][Medline]
  58. Mancuso P, Burlini A, Pruneri G, Goldhirsch A, Martinelli G, Bertolini F. Resting and activated endothelial cells are increased in the peripheral blood of cancer patients Blood 2001;97:3658-3661.[Abstract/Free Full Text]
  59. Beerepoot LV, Mehra N, Vermaat JS, Zonnenberg BA, Gebbink MF, Voest EE. Increased levels of viable circulating endothelial cells are an indicator of progressive disease in cancer patients Ann Oncol 2004;15:139-145.[Abstract/Free Full Text]
  60. George F, Brouqui P, Boffa MC, et al. Demonstration of Rickettsia conorii-induced endothelial injury in vivo by measuring circulating endothelial cells, thrombomodulin, and von Willebrand factor in patients with Mediterranean spotted fever Blood 1993;82:2109-2116.[Abstract/Free Full Text]
  61. Percivalle E, Revello MG, Vago L, Morini F, Gerna G. Circulating endothelial giant cells permissive for human cytomegalovirus (HCMV) are detected in disseminated HCMV infections with organ involvementCirculating endothelial giant cells permissive for human cytomegalovirus (HCMV) are detected in disseminated HCMV infections with organ involvement. J Clin Invest 1993;92:663-670.[ISI][Medline]
  62. Beerepoot LV, Mehra N, Linschoten F, et al. Circulating endothelial cells in cancer patients do not express tissue factor Cancer Lett 2004;213:241-248.[CrossRef][ISI][Medline]
  63. Mutin M, Canavy I, Blann A, Bory M, Sampol J, Dignat-George F. Direct evidence of endothelial injury in acute myocardial infarction and unstable angina by demonstration of circulating endothelial cells Blood 1999;93:2951-2958.[Abstract/Free Full Text]
  64. Quilici J, Banzet N, Paule P, et al. Circulating endothelial cell count as a diagnostic marker for non-ST-elevation acute coronary syndromes Circulation 2004;110:1586-1591.[Abstract/Free Full Text]
  65. Lee KW, Lip GY, Tayebjee M, Foster W, Blann AD. Circulating endothelial cells, von Willebrand factor, interleukin-6, and prognosis in patients with acute coronary syndromes Blood 2005;105:526-532.[Abstract/Free Full Text]
  66. Wang C, Li H, Fu P, Zhang S, Xiu R. Serum C-reactive protein and circulating endothelial cells in patients with acute myocardial infarction Clin Hemorheol Microcirc 2005;32:287-296.[ISI][Medline]
  67. Freestone B, Chong AY, Nadar S, Lee KW, Lip GYH, Blann AD. Circulating endothelial cells in atrial fibrillation with and without acute cardiovascular disease Thromb Haemost 2005;94:702-706.[ISI][Medline]
  68. Nadar S, Lip GYH, Blann AD. Circulating endothelial cells in acute ischaemic stroke Thromb Haemost 2005;94:707-712.[ISI][Medline]
  69. Blann AD, Naqvi T, Waite M, McCollum CN. von Willebrand factor and endothelial cell damage in essential hypertension J Hum Hypertens 1993;7:107-111.[ISI][Medline]
  70. Chong AY, Lip GYH, Freestone B, Blann AD. Increased circulating endothelial cells in acute congestive heart failure: comparison with von Willebrand factor and soluble E selectin Eur J Heart Fail 2006;8:167-172.[CrossRef][ISI][Medline]
  71. McClung JA, Naseer N, Saleem M, et al. Circulating endothelial cells are elevated in patients with type 2 diabetes mellitus independently of HbA(1)c Diabetologia 2005;48:345-350.[CrossRef][ISI][Medline]
  72. Koc M, Richards HB, Bihorac A, Ross EA, Schold JD, Segal MS. Circulating endothelial cells are associated with future vascular events in hemodialysis patients Kidney Int 2005;67:1078-1083.[CrossRef][ISI][Medline]
  73. Mutunga M, Fulton B, Bullock R, et al. Circulating endothelial cells in patients with septic shock Am J Respir Crit Care Med 2001;163:195-200.[Abstract/Free Full Text]
  74. Kocher AA, Schuster, MD, Szabolcs MJ, et al. Neovascularisation of ischaemic myocardium by human bone marrow-derived angioblasts prevents cardiomyocyte apoptosis, reduces remodelling and improves cardiac function Nat Med 2001;7:430-436.[CrossRef][ISI][Medline]
  75. Asahara T, Matsuda H, Takahashi T, et al. Bone marrow origin of endothelial progenitor cells responsible for postnatal vasculogenesis in physiological and pathological neovascularisation Circ Res 1999;85:221-228.[Abstract/Free Full Text]
  76. Szmitko PE, Fedak PW, Weisel RD, Stewart DJ, Kutryk MJ, Verma S. Endothelial progenitor cells: new hope for a broken heart Circulation 2003;107:3093-3100.[Free Full Text]
  77. Rafii S, Meeus S, Dias S, et al. Contribution of marrow-derived progenitors to vascular and cardiac regeneration Semin Cell Dev Biol 2002;13:61-67.[CrossRef][ISI][Medline]
  78. Adams V, Lenk K, Linke A, et al. Increase of circulating endothelial progenitor cells in patients with coronary artery disease after exercise-induced ischemia Arterioscler Thromb Vasc Biol 2004;24:684-690.[Abstract/Free Full Text]
  79. Hill JM, Zalos G, Halcox JP, et al. Circulating endothelial progenitor cells, vascular function, and cardiovascular risk N Engl J Med 2003;348:593-600.[Abstract/Free Full Text]
  80. Eizawa T, Ikeda U, Murakami Y, et al. Decrease in circulating endothelial progenitor cells in patients with stable coronary artery disease Heart 2004;90:685-686.[Free Full Text]
  81. Roberts N, Jahangiri M, Xu Q. Progenitor cells in vascular disease J Cell Mol Med 2005;9;:583-591.[ISI][Medline]
  82. Leone AM, Rutella S, Bonanno G, et al. Mobilization of bone marrow-derived stem cells after myocardial infarction and left ventricular function Eur Heart J 2005;26:1196-1204.[Abstract/Free Full Text]
  83. Massa M, Rosti V, Ferrario M, et al. Increased circulating hematopoietic and endothelial progenitor cells in the early phase of acute myocardial infarction Blood 2005;105:199-206.[Abstract/Free Full Text]
  84. Shintani S, Murohara T, Ikeda H, et al. Mobilisation of endothelial progenitor cells in patients with acute myocardial infarction Circulation 2001;103:2776-2779.[Abstract/Free Full Text]
  85. Steiner S, Niessner A, Ziegler S, et al. Endurance training increases the number of endothelial progenitor cells in patients with cardiovascular risk and coronary artery disease Atherosclerosis 2005;181:305-310.[CrossRef][ISI][Medline]
  86. Walter DH, Rittig K, Bahlmann FH, et al. Statin therapy accelerates reendothelialization: a novel effect involving mobilization and incorporation of bone marrow-derived endothelial progenitor cells Circulation 2002;105:3017-3024.[Abstract/Free Full Text]
  87. Vasa M, Fichtlscherer S, Adler K, et al. Increase in circulating endothelial progenitor cells by statin therapy in patients with stable coronary artery disease Circulation 2001;103:2885-2890.[Abstract/Free Full Text]
  88. Ingram DA, Mead LE, Tanaka H, et al. Identification of a novel hierarchy of endothelial progenitor cells using human peripheral and umbilical cord blood Blood 2004;104:2752-2760.[Abstract/Free Full Text]
  89. Burger PE, Coetzee S, McKeehan WL, et al. Fibroblast growth factor receptor-1 is expressed by endothelial progenitor cells Blood 2002;100:3527-3535.[Abstract/Free Full Text]
  90. Walenta K, Friedrich EB, Sehnert F, Werner N, Nickenig G. In vitro differentiation characteristics of cultured human mononuclear cells-implications for endothelial progenitor cell biology Biochem Biophys Res Commun 2005;333:476-482.[CrossRef][ISI][Medline]
  91. Nakatani K, Takeshita S, Tsujimoto H, Kawamura Y, Tokutomi T, Sekine I. Circulating endothelial cells in Kawasaki disease Clin Exp Immunol 2003;131:536-540.[CrossRef][ISI][Medline]
  92. Ingram DA, Caplice NM, Yoder MC. Unresolved questions, changing definitions, and novel paradigms for defining endothelial progenitor cells Blood 2005;106:1525-1531.[Abstract/Free Full Text]
  93. Schmeisser A, Garlichs CD, Zhang H, et al. Monocytes coexpress endothelial and macrophagocytic lineage markers and form cord-like structures in Matrigel under angiogenic conditions Cardiovasc Res 2001;49:671-680.[Abstract/Free Full Text]
  94. Rehman J, Li J, Orschell CM, March KL. Peripheral blood "endothelial progenitor cells" are derived from monocyte/macrophages and secrete angiogenic growth factors Circulation 2003;107:1164-1169.[Abstract/Free Full Text]
  95. Rohde E, Malischnik C, Thaler D, et al. Blood monocytes mimic endothelial progenitor cells Stem Cells 2006;24:351-367.
  96. Gulati R, Jevremovic D, Peterson TE, et al. Diverse origin and function of cells with endothelial phenotype obtained from adult human blood Circ Res 2003;93:1023-1025.[Abstract/Free Full Text]
  97. Romagnani P, Annunziato F, Liotta F, et al. CD14+CD34low cells with stem cell phenotypic and functional features are the major source of circulating endothelial progenitors Circ Res 2005;97:314-322.[Abstract/Free Full Text]
  98. Lin Y, Weisdorf DJ, Solovey A, et al. Origins of circulating endothelial cells and endothelial outgrowth from blood J Clin Invest 2000;105:71-77.[ISI][Medline]
  99. Rehman J, Li J, Orschell CM, March KL. Peripheral blood "endothelial progenitor cells" are derived from monocyte/macrophages and secrete angiogenic growth factors Circulation 2003;107:1164-1169.[Abstract/Free Full Text]
  100. Fernandez Fernandez Pujol B, Lucibello FC, Gehling UM, et al. Endothelial-like cells derived from human C14 positive monocytes Differentiation 2000;65:287-300.[CrossRef][ISI][Medline]
  101. Werner N, Kosiol S, Schiegl T, et al. Circulating endothelial progenitor cells and cardiovascular outcomes N Engl J Med 2005;353:999-1007.[Abstract/Free Full Text]
  102. Woywodt A, Blann AD, Kirsch T, et al. Isolation and enumeration of circulating endothelial cells by immunomagnetic isolation: proposal of a definition and a consensus protocol J Thromb Haemost 2006;4:671-677.[CrossRef][ISI][Medline]
  103. Bonello L, Basire A, Sabatier F, Paganelli F, Dignat-George F. Endothelial injury induced by coronary angioplasty triggers moblization of endothelial progenitor cells in patients with stable coronary artery disease J Thromb Haemost 2006;4:979-981.[CrossRef][ISI][Medline]



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